Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on June 13, 2024, the state cited 6 findings at The Enclave of Franklin. 4 of them had already been cited at the previous review. Across the 145 Massachusetts residences with a published report, the median is 6.
This page covers one review, not a history, and it is not a score or a ranking. A finding means the state identified something the residence has to correct; it does not on its own mean a resident was harmed. The state does not publish what happened after this review, so a finding listed here may since have been fixed. Where the state withheld private details, such as a resident's medication or the date of an incident, the text reads [redacted].
Facility details
What the state found
6 findings · 4 repeatEmergency call responseMissing e-call response time not compliant with the ALR policy. Missing documentation of hourly safety checks.Repeat finding▼
How quickly staff answer a resident's emergency call button.
EOEA was not able to review the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.
Documentation of the Personalized Emergency Response procedures was not available at the time of the compliance review.
The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulations to provide timely assistance to a Resident in the event of an emergency needs situation.
Documentation of hourly checks in the Specialized Care Residence neighborhood for May 2024, had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00pm and 7:00am.
This was also cited at the previous compliance review.
General Requirements for an ALR - Service and Service Coordination Requirements: Emergency Response
651 CMR 12.04(2)(b)(3.)(b.)(c.)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements. Insufficient evidence to determine safe Self-Administered Medication Management (SAMM)Repeat finding▼
The residence's own program for auditing and improving the care it gives.
EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the first quarter of 2024 calendar year.
Documentation to support that the required quarterly medication documentation audit was conducted in the first quarter of the 2024 calendar year was missing.
EOEA observed three RCA staff providing medication assistance to eight Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
One Resident SAMM MAR documentation was missing a signature for [redacted] missing reason code for medication omission.
Four Resident’s Family filled medication cassettes were missing a label with resident name, date, and room number.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Performance Improvement
651 CMR12.04(10)(c)2.(e)
Resident screening and assessment · Resident care plansInconsistent with documenting all requirements of Assessments and Service Plans.Repeat finding▼
Resident screening and assessment: Checking, before and during residency, that the residence can meet a resident's needs.
Resident care plans: The written plan describing the care each resident is assessed to need.
The state cited these together under one finding.
EOEA reviewed the records of eight Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.
Five records were without documentation to confirm the initial assessment was conducted prior to move-in.
Two records were missing documentation of a Service Plan reassessment required within 30 days after the commencement of residency.
Five (5) records were without documentation to confirm the ability of the Resident to manage medication.
Four records were missing documentation of supervised access cooking capacity.
Four SCR service plan records were missing Documentation of individualized enrichment activities provided to the resident.
Eight records were missing documentation of specified staff having key or access codes to the Resident’s unit.
Four records were missing documentation of reassessment findings on the need for assistance in emergency situations.
Two records were missing documentation of all Service Plans after a reassessment within 30 days after the commencement of residency.
Four records were missing documentation of how the Residence provides 24-hours per day, onsite staff.
Four records were without documentation to confirm that assessments noted the name and scope of any Legal Representative
This was also cited at the previous compliance review.
General Requirements for an ALR: -Screening and Assessment -Service Plan Development and Requirements
651 CMR 12.04(7)(b) 651 CMR 12.04(8)(a) 2. a.b.3. 651 CMR 12.04(6)(b) 651 CMR 12.04(7)(b) 651 CMR 12.04(1)(a)
Controlled medication handlingControlled Substances management and count not conducted in accordance with the Residence's policy.▼
How tightly the residence tracks medications that are subject to abuse.
EOEA reviewed the Controlled Substances policies and procedures intended to prevent the theft or diversion of controlled substances prescribed to the Residents who participate in SAMM and LMA.
Documentation to support the Residence is conducting Controlled Substance count audits in accordance with the stated frequency as described in its Controlled
Substance policy was missing for all years reviewed.
Upon review of the controlled substance practices of the Residence, it was discovered that the Residence was inconsistent in documenting a controlled substance count for all Residents prescribed a controlled substance(s) in accordance with the Residence policy for all years reviewed.
General Requirements for an ALR: Controlled Substances
651 CMR 12.05(4)
Resident recordsInconsistent documentation of information necessary for the continuity of care.▼
Records that keep a resident's care information complete and available to staff.
EOEA reviewed the current 90-day Correspondence Logs for Traditional and Special Care Unit required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents
The Documentation for the Traditional Unit Correspondence Log was not available to EOEA at the time of the compliance review.
Record Requirements: Correspondence Log
651 CMR 12.05(4)
Staff trainingMissing or inconsistent documentation of Introductory Visit processRepeat finding▼
Training and skills checks the residence must give and document for its staff.
EOEA reviewed the records of eight Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers.
Eight records were without documentation to support that Introductory Visits were consistently conducted by a nurse and conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care Services.
Corrective Actions.
This was also cited at the previous compliance review.
Training Requirements Introductory Visits
651CMR 12.07(7)
Glossary
Abbreviations the state uses without explaining themWhat the residence must doThe residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when. The state also asked for specific proof, listed here as written.▼
Submit to EOEA the following:
Documentation that all personal care staff have completed current Introductory Visits with a nurse for all Residents.
Documentation that all care staff and nursing have been trained on Control Substance policy and procedures.